=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487179925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN L IMBER PSYCHOLOGIST, LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2017
-----------------------------------------------------
Last Update Date | 09/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11522 NE 21ST ST STE 100
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-3025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-456-5450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6688 WATERTON CIR
-----------------------------------------------------
City | MUKILTEO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98275-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-563-3099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH61027314
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 246ZE0500X
-----------------------------------------------------
Taxonomy Name | EEG Specialist/Technologist
-----------------------------------------------------
License Number | LH61027314
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 246ZE0500X
-----------------------------------------------------
Taxonomy Name | EEG Specialist/Technologist
-----------------------------------------------------
License Number | PSY32640
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY32640
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------